Headache

Migraine – Preventative Medication

As mentioned multiple times before, keeping a diary to keep track of how often you are suffering with migraine attacks and how long they are lasting can be helpful in identifying whether or not you are likely to benefit from preventative treatment.

There is guidance to decide whether or not you fit this criteria:

  1. Experience frequent disabling attacks:
    • two or more attacks per month which last 3 or more days at a time
    • quality of life is severely impaired
  1. Are at risk of Medication Overuse Headache
  2. Normal pain-killers or triptans cannot be prescribed or are ineffective
  3. Atypical migraine: hemiplegic migraine (a sub-type of Migraine with aura which causes paralysis of one side of the body) or a persistent aura.

What does it do?

I like to think of preventative medication as a sort of “reset” button: they make you less likely to have a migraine.  Essentially the aim of any preventative treatment is to reduce both the severity of the migraine and the frequency of attacks.  The best preventative can only reduce the frequency and severity of attacks by 50% so it is definitely not a cure.  It is still important to try an assess potential triggers and try to minimise them where possible.

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None of the medications we suggest for migraine prevention have been developed specifically for the treatment of migraine.  There are a few main classes of medications which I will allude to:

  • Beta-blockers
  • Anti-epileptics
  • Antidepressants:
    • Tricyclic Antidepressants (TCAs)
    • Selective Noradrenaline Re-uptake Inhibitors (SNRIs)
  • Anti-hypertensives

There are also injectable treatments which I will discuss in a separate post.

Beta-blockers

The most common of these used is Propranolol.  Beta-blockers are often the first preventative medication tried.  They are well tolerated with few side-effects (vivid dreams, fatigue, reduced exercise tolerance, dizziness and erectile-dysfunction in men).  It is not suitable for asthmatics.

Anti-epileptics

The main one used nowadays is Topiramate.  I call this medication “marmite”: patients either love it or hate it.  It works well if you don’t get side-effects, and some people don’t.  Others on the other hand find the tingling in hands and feet, weight loss, mood changes (specifically unmasking of anxiety or depression) and cognitive slowing too difficult to deal with.  There’s no way of telling if you’ll be lucky or not.  This is also the only one that does not cause weight gain: in fact it usually gives the opposite effect.

Antidepressants

This includes my favourite class of migraine preventative: TCAs.  This is an old fashioned antidepressant but we use it a much lower dose in this setting.  Amitriptyline or (as a patient once described it to me) it’s “more refined brother” Nortriptyline is taken 2 hours before bedtime to mitigate its main side-effect: drowsiness.  This is actually a pretty good thing as it guarantees a fantastic nights sleep.  The other major side-effect is dry mouth.  Some people have vivid dreams and weight gain with it.

The other class of antidepressant SNRI is useful if people also suffer with anxiety or depression.  Venlafaxine  or Mirtazepine tend to be more effective as migraine preventers than first-line antidepressants such as sertraline, fluoxetine or citalopram.

Anti-hypertensives

This includes the relatively new kid on the block: Candesartan.  This has a very low side-effect profile apart from dizziness due to…well…low blood pressure.  The other medication which is used more commonly overseas is (as a patient once described it to me is Flunarazine which is a calcium-channel blocker.  Unfortunately it’s difficult to get hold of in the UK so its use is limited.

Others

Some patients still come to the clinic on medications such as gabapentin, pizotifen, sodium valproate, verapamil…  these are often unsuccessful.  Pizotifen does have a place in migraine prevention, but for some reason it tends to work better for children.  Gabapentin has been shown to be ineffective for migraine (although it still features in the guidelines which have yet to be updated) and verapamil is useful for Cluster Headache but not Migraine.

But what if I don’t want to take medication?

Lots of people don’t like taking medications because of the side-effects listed above.  There have been studies on supplements and vitamins and people are always keen to know what the more natural remedies are.

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  • Riboflavin (Vitamin B2): at a dose of 400mg this has been shown to reduce the frequency (but not severity or duration) of migraine attacks.  Main side-effect: turns urine more yellow.
  • Magnesium: usually as citrate or maleate as they are better tolerated.  There is evidence that this can reduce the frequency and severity of attacks.  It is also beneficial in menstrual migraine for pre-menstrual attacks.  Dose is 600mg to be taken at night and main side-effects are abdominal cramps and diarrhoea.
  • Co-enzyme Q10: again reduces the frequency but not the severity of attacks.  Dose is 300mg per day.

The other option that people often ask us about is Botox.  But that is a discussion for another article…

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5 thoughts on “Migraine – Preventative Medication

  1. I am on Pre- gablin 200mgs a day and Proprananol 80mgs daily. I keep a diary and have in general 3/4 migraines a month. Since above medication I have less frequent auras, I have always had migraines, but 10 years ago they became awful, could not manage my life at work often.
    I try desperately to manage all the triggers you mentioned , though my job as a psychotherapist might cause work tress from time to time, I try to counter act with Pilates and Yoga.
    I would love to know if I would ever manage to come off the above??? Why did 4 migraines a year become 4 a month?
    thanks.

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    1. Hi anthea, it sounds like you’ve been having a horrid time. Pregabalin isn’t recommended any longer for migraine unfortunately. The dose of propranolol could be increased further if it has been helpful….

      Unfortunately migraine can change from time to time. Triggers are often multiple and stress can certainly be a factor. It’s worth looking at what has happened 12-24 hours before a migraine hits to see if there’s a common link for example are they always at the same time of the week or day?

      Hope that helps

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  2. On atenolol for 26 years, pizotifen for 4 years, magnesium daily. Rizatriptan as brilliant emergency medication. Can sometimes get daily migraines during the night. Had first Botox injections in January which made them worse. Migraines most days. Now take atenolol in the morning, improvement in migraines since. Next Botox delayed from April to June. Will be getting a daith ear pierce next. Try all self help methods. Was under migraine clinic for a few years. Good luck to everyone.🌞

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  3. I have “classic” migraine (with aura): the three-day-long flavour. I’m 54, and have had migraine since I was 25: originally the “common” pattern, becoming “classic” ten years later.

    I tried many prophylactic treatments (citalopram, amitriptyline, propranalol, for instance). They all had side effects that eventually (or rapidly) outweighed any marginal benefit. I also tried mitigation supplements (B2, Mg+Zn, CoQ10, etc.), and none of them worked noticeably.

    Finally, I was prescribed sodium valproate, an anti-epileptic. This isn’t for the faint-hearted (or rather, lily-livered): you have to have a full blood count and liver enzymes set to check if you’re safe to take it, and the same again after a month to check it isn’t harming your liver. However…it switched off my migraine. Completely. Very quickly – far quicker than predicted. Within a couple of weeks of starting it, I’d gone from being a chronic migraineur, with more migraine days per week than not, to having none. At all.

    I find it hard to express what it’s like to go from permanently debilitated to migraine-free. Last year, I had no recorded migraines. This year, I had a brief burst of three in February. I upped my dosage to 400mg bd (twice daily) for a couple of weeks until they stopped, then dropped back down to my current 300mg bd. Right now, I’m dealing with a mild chest infection that’s making me cough almost non-stop – migraineurs will know that’s a guaranteed trigger – and…no sign of anything more than a mild (and completely understandable) headache.

    So, I’m going to disagree with the statement that: “The best preventative can only reduce the frequency and severity of attacks by 50%”. Everyone is different of course but, for me, valproate has been to all intents and purposes a cure – or at least a 99+% preventative.

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    1. Hi Jon thank you for your comment. We aim for a 50% reduction but as you’ve found sometimes we can switch it of as the case has been with you which is excellent. In our best preventatives 40% of people have a 50% reduction or better (which takes into account the 100% reductions) but not everyone is so lucky.

      Valproate is a very good preventative but we are not recommended to use it in women any longer which is why it does not always spring to mind, and as you have pointed out it needs monitoring.

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